Alcoholic liver disease (ALD)
- ALD is a continuum from fatty liver to steatohepatitis and liver cirrhosis.
- ALD increases the risk of hepatocellular carcinoma, and some patients develop acute alcoholic hepatitis resulting from a drinking spree.
- The risk limit for alcohol consumption is 20 g a day of absolute alcohol for women and 30 g for men – however, there are no completely safe limits for alcohol consumption.
- Binge drinking is harmful regardless of the average alcohol consumption.
- The aim is to recognize early stages of alcoholic liver disease, to stop alcohol consumption in time before the disease progresses and to treat complications of advanced disease.
- A person may have several risk factors for liver disease (such as alcohol and obesity), which should be treated simultaneously. Alcohol also speeds up the progression of liver damage from other causes (NAFLD, chronic viral hepatitis).
- See also the article Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) (Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH)).
Examination and diagnosis
- For diagnosis, a history of high alcohol consumption and clinical or biological proof of liver damage is required.
- Alcohol history
- Proof of high alcohol consumption
- AUDIT test to assess alcohol consumption
- If the alcohol history remains uncertain or unreliable, other indicators can be used, as necessary.
- Direct alcohol markers (breath alcohol, serum ethanol, blood phosphatidylethanol)
- Indirect alcohol markers (AST/ALT ratio, MCV, CDT) are low in sensitivity and should therefore be combined with other laboratory tests, history and clinical findings
- See also Recognition of alcohol and drug abuse (Recognition of alcohol and drug abuse)
- Basic tests when suspecting ALD (Basic blood count with platelet count, plasma ALT, AST, ALP, bilirubin, prothrombin time or INR, albumin, serum prealbumin, plasma potassium, sodium, creatinine, and fasting glucose)
- Upper abdominal ultrasonography
- Tests for alternative or concomitant causes T1. See also article on Assessing patients with abnormal liver function test results (Assessing a patient with an abnormal liver function test result).
- Detecting concomitant risk factors for liver disease
- Detecting alcoholic hepatitis
- Acute jaundice, liver failure, general symptoms, resulting from excessive drinking
- Patients with alcoholic hepatitis need emergency specialized care.
- Detecting liver cirrhosis
- See also Cirrhosis of the liver (Cirrhosis of the liver).
- Clinical signs of liver cirrhosis
- Spider naevi, palmar erythema, jaundice, ascites, muscular wasting
- Some patients with cirrhosis may be asymptomatic and may have normal liver enzyme values. Detecting such ‘silent’ cirrhosis is essential for the prognosis and for screening for complications particularly in heavy drinkers.
- Screening for complications
- Oesophageal varices (Haematemesis) (gastroscopy), hepatocellular carcinoma (Cancer of the liver and the biliary tract) (ultrasonography)
- Assessment of nutritional status
- The aim is to eat several meals a day, 35 kcal/kg/day of energy and 1.2–1.5 g/kg/day of protein.
- Detection of other diseases associated with ALD
- The most important treatment improving the prognosis is stopping alcohol consumption.
- Management of concomitant risk factors of liver disease
- Weight reduction, avoiding medication and natural products that put a strain on the liver, smoking cessation
- Treatment plans for patients with mild disease should be made in primary health care.
- If drinking continues, about 20% of patients with ALD will develop cirrhosis.
- The aim of follow-up is to motivate patients to reduce their alcohol consumption and to detect any signs of progressive disease or complications requiring treatment.
Consulting specialized care
- Specialized care should be consulted if the patient has signs of progressed disease.
- Clinical or biochemical signs, imaging or elastography
- In specialized care
- Confirming the diagnosis in unclear cases
- Elastography; liver biopsy, as necessary
- Planning the treatment of progressed disease and guidance for further follow-up in primary health care
- Exclusion of hepatocellular carcinoma (ultrasonography)
- Screening for, and treatment of, oesophageal varices (gastroscopy)
- Treatment of other complications of portal hypertension (ascites, encephalopathy, hepatorenal syndrome)
- Assessment of the possibility of liver transplantation in selected patients who were capable of stopping their alcohol consumption and whose liver cirrhosis remains decompensated (ascites, jaundice, encephalopathy, recurrent bleeding from oesophageal varices) despite abstinence
- Consultation of an addiction medicine specialist and a social worker
- The prognosis of patients with liver cirrhosis who continue to drink after appropriate primary assessment is very poor, and in most cases they do not benefit from follow-up in specialized care.
Table 1. Workup in patients with alcoholic liver disease
. European Association for the Study of the Liver. Electronic address: email@example.com., European Association for the Study of the Liver.. EASL Clinical Practice Guidelines: Management of alcohol-related liver disease. J Hepatol 2018;69(1):154-181. [PMID:29628280] https://doi.org/10.1016/j.jhep.2018.03.018
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Alcoholic liver disease (ALD)
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